Your first name and initial

U.S. Nonresident Alien Income Tax Return
For the year January 1–December 31, 1995, or other tax year beginning , 1995, and ending , 19

OMB No. 1545-0089

Department of the Treasury Internal Revenue Service

Last name

Identifying or social security number

Please print or type

Present home address (number, street, and apt. no., or rural route). If a P.O. box, see page 5 of instructions.

Check if:

Individual Estate or Trust

City, town or post office, state, and ZIP code. If a foreign address, see page 5 of instructions. Country Of what country were you a citizen or national during the tax year? Give address outside the United States to which you want any refund check mailed. If same as above, write “Same.”

For Paperwork Reduction Act Notice, see page 1 of instructions.

Give address in the country where you are a permanent resident. If same as above, write “Same.”

Attach Copy B of your Forms W-2, W-2G, and 1099-R here

Filing Status and Exemptions for Individuals (See page 5 of the instructions.) Filing status. Check only one box. 1 2 3 4 5 6 Single resident of Canada or Mexico, or a single U.S. national Other single nonresident alien
Married resident of Canada or Mexico, or a married U.S. national Married resident of Japan or the Republic of Korea
If your spouse is filing a return, you cannot take an exemption for him or her.
19 ). (See page 5 of inst.)



Other married nonresident alien Qualifying widow(er) with dependent child (year spouse died

Caution: If your parent (or someone else) can claim you as a dependent on his or her tax return, do not check box 7a. But be sure to check the box below line 35 on page 2.


Dependents:* (1) First name Last name

(2) Dependent’s social security number. If born in 1995, see page 6.

(3) Dependent’s relationship to you

(4) No. of months lived in your home in 1995

. . . . . . . . . . . . . . .

. . . . . . . . . . . . . . .

No. of boxes checked on 7a and 7b No. of your children on 7c who: *lived with you **didn’t live with you due to divorce or separation **Dependents on 7c not entered above Add numbers entered on lines above

*Applies generally only to residents of Canada, Mexico, Japan, and the Republic of Korea and to U.S. nationals. (See page 5 of instructions.) **Applies generally only to residents of Canada and Mexico and to U.S. nationals. (See page 5 of instructions.)

d If your child didn’t live with you but is claimed as your dependent under a pre-1985 agreement, check here e Total number of exemptions claimed
Income Effectively Connected With U.S. Trade/Business

Enclose, but do not attach, any payment with your return.

8 9a b 10 11 12 13 14 15 16a 17a 18 19 20 21 22 23 24 25 26 27 28 29 30 31

Wages, salaries, tips, etc. Attach Form(s) W-2 Taxable interest income 9b Tax-exempt interest (see page 7). DO NOT include on line 9a Dividend income Taxable refunds, credits, or offsets of state and local income taxes (see page 7) Scholarship and fellowship grants. Attach explanation (see page 7) Business income or (loss). Attach Schedule C or C-EZ (Form 1040) Capital gain or (loss). If required, attach Schedule D (Form 1040) (see page 7) Other gains or (losses). Attach Form 4797 16a 16b Taxable amount (see page 7) Total IRA distributions 17b Taxable amount (see page 8) Total pensions and annuities 17a Rental real estate, royalties, partnerships, trusts, etc. Attach Schedule E (Form 1040) Farm income or (loss). Attach Schedule F (Form 1040) Unemployment compensation (see page 9) Other income. List type and amount—see page 9 22 Total income exempt by a treaty from page 5, Item M Add lines 8, 9a, 10–15, 16b, and 17b–21. This is your total effectively connected income 24 IRA deduction (see page 9) 25 Moving expenses. Attach Form 3903 26 Self-employed health insurance deduction 27 Keogh & self-employed SEP plans. If SEP, check 28 Penalty on early withdrawal of savings 29 Scholarship and fellowship grants excluded Add lines 24 through 29 (see page 10). These are your total adjustments Subtract line 30 from line 23. Enter here and on line 32. This is your adjusted gross income
Cat. No. 11364D

8 9a 10 11 12 13 14 15 16b 17b 18 19 20 21 23


30 31



Form 1040NR (1995)



Tax Computation

32 33 34 35 36 37 38 39


40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59

Amount from line 31 (adjusted gross income) Itemized deductions from page 3, Schedule A, line 17 Subtract line 33 from line 32. If line 33 is more than line 32, enter -0Exemptions (see page 10) Caution: If your parent (or someone else) can claim you as a dependent, check here Taxable income. Subtract line 35 from line 34. If line 35 is more than line 34, enter -0Tax. Check if from Tax Table, Tax Rate Schedules, Capital Gain Tax Worksheet, Form 8615 (see page 10). Amount from Form(s) 8814 or Additional taxes. Check if from Form 4970 Form 4972 Add lines 37 and 38 Credit for child and dependent care expenses. Attach Form 2441 40 41 Foreign tax credit. Attach Form 1116 Form 3800 Other credits (see page 11). Check if from 42 Form 8801 Form (specify) Form 8396 Add lines 40 through 42 Subtract line 43 from line 39. If line 43 is more than line 39, enter -0Alternative minimum tax (see page 11). Attach Form 6251 Recapture taxes (see page 12). Check if from Form 4255 Form 8611 Form 8828 Tax on income not effectively connected with a U.S. trade or business from page 4, line 80 Social security and Medicare tax on tip income not reported to employer. Attach Form 4137 Tax on qualified retirement plans, including IRAs. If required, attach Form 5329 Transportation tax (see page 12) Household employment taxes. Attach Schedule H (Form 1040) Add lines 44 through 51. This is your total tax 53 Federal income tax withheld. If any is from Form(s) 1099, check 54 1995 estimated tax payments and amount applied from 1994 return 55 Amount paid with Form 4868 (extension request) 56 Excess social security and RRTA tax withheld (see page 13) Other payments. Check if from Form 2439 Form 4136 57 58 Credit for amount paid with Form 1040-C 59a 59b 60a 60b

32 33 34 35 36 37 38 39

43 44 45 46 47 48 49 50 51 52


Other Taxes

U.S. tax withheld at source: a From page 4, line 77 b By partnerships under section 1446 (from Form(s) 8805 or 1042-S) 60 U.S. tax withheld on dispositions of U.S. real property interests: a From Form(s) 8288-A b From Form(s) 1042-S 61 Add lines 53 through 60b. These are your total payments

61 62 63

Refund or Amount You Owe

62 If line 61 is more than line 52, subtract line 52 from line 61. This is the amount you OVERPAID 63 Amount of line 62 you want REFUNDED TO YOU 64 Amount of line 62 you want APPLIED TO YOUR 1996 64 ESTIMATED TAX 65 If line 52 is more than line 61, subtract line 61 from line 52. This is the AMOUNT YOU OWE. For details on how to pay, including what to write on your payment, see page 14 Estimated tax penalty (see page 14). Also, include on line 65 66



Sign Here
Keep a copy of this return for your records.

Under penalties of perjury, I declare that I have examined this return and accompanying schedules and statements, and to the best of my knowledge and belief, they are true, correct, and complete. Declaration of preparer (other than taxpayer) is based on all information of which preparer has any knowledge. Your signature Date Your occupation in the United States

Paid Preparer’s Use Only

Preparer’s signature Firm’s name (or yours if self-employed) and address

Date Check if self-employed EIN ZIP code

Preparer’s social security no.

Form 1040NR (1995)



Schedule A—Itemized Deductions (See pages 9, 14, 15, and 16.)
State and Local Income Taxes Gifts to U.S. Charities
1 2 3 State income taxes Local income taxes Add lines 1 and 2 Caution: If you made a gift and received a benefit in return, see page 15. Contributions by cash or check. If you made any gift of $250 or more, see page 15 Other than cash or check. If you made any gift of $250 or more, see page 15. If over $500, you MUST attach Form 8283 Carryover from prior year Add lines 4 through 6 Casualty or theft loss(es). Attach Form 4684 Unreimbursed employee expenses—job travel, union dues, job education, etc. If required, you MUST attach Form 2106 or Form 2106-EZ. See page 16 9 Tax preparation fees Other expenses. See page 16 for expenses to deduct here. List type and amount 10 1 2 3


4 5


5 6 7 8

6 7

Casualty and Theft Losses


9 Job Expenses and Most Other Miscellaneous Deductions 10 11

11 12 13 Add lines 9 through 11 Enter the amount from Form 1040NR, line 32 Multiply line 13 by 2% (.02) 12 13 14 15

14 15 16 Other Miscellaneous Deductions

Subtract line 14 from line 12. If line 14 is more than line 12, enter -0Other—certain expenses of disabled employees, estate tax on income of decedent, etc. List type and amount

16 17 Total Itemized Deductions Is Form 1040NR, line 32, over $114,700 (over $57,350 if you checked filing status box 3, 4, or 5 on page 1 of Form 1040NR)? No. Your deduction is not limited. Add the amounts in the far right column for lines 3 through 16. Enter the total here and on Form 1040NR, line 33. Yes. Your deduction may be limited. See page 16 for the amount to enter here and on Form 1040NR, line 33. 17

Form 1040NR (1995)



Tax on Income Not Effectively Connected With a U.S. Trade or Business
Attach Forms 1042-S, SSA-1042S, RRB-1042S, 1001 or similar form. Enter amount of income under the appropriate rate of tax (see page 16)
(b) 10% (c) 15% (d) 30% (e) Other (specify)

Nature of income

(a) U.S. tax withheld at source



67 67a 67b 68a 68b 68c 69 70 71 72 73 74 75 76

Dividends paid by: a U.S. corporations b Foreign corporations 68 Interest: a Mortgage b Paid by foreign corporations c Other 69 Industrial royalties (patents, trademarks, etc.) 70 Motion picture or T.V. copyright royalties 71 Other royalties (copyrights, recording, publishing, etc.) 72 Real property income and natural resources royalties 73 Pensions and annuities 74 Social security benefits 75 Gains (include capital gain from line 83 below) 76 Other (specify)

77 77 78


Total U.S. tax withheld at source. Add column (a) of lines 67a through 76. Enter the total here and on Form 1040NR, line 59a Add lines 67a through 76 in columns (b)–(e)

79 80

79 Multiply line 78 by rate of tax at top of each column Tax on income not effectively connected with a U.S. trade or business. Add columns (b)–(e) of line 79. Enter the total here and on Form 1040NR, line 47


Capital Gains and Losses From Sales or Exchanges of Property
(b) Date acquired (mo., day, yr.) (c) Date sold (mo., day, yr.) (d) Sales price (e) Cost or other basis (f) LOSS If (e) is more than (d), subtract (d) from (e) (g) GAIN If (d) is more than (e), subtract (e) from (d)

Enter only the capital gains and losses from property sales or exchanges that are from sources within the United States and not effectively connected with a U.S. business. Do not include a gain or loss on disposing of a U.S. real property interest. Report these gains and losses on Schedule D (Form 1040).


Kind of property and description (if necessary, attach statement of descriptive details not shown below)

Report property sales or exchanges that are effectively connected with a U.S. business on Schedule D (Form 1040), Form 4797, or both.


Add columns (f) and (g) of line 81

82 ( 83



Capital gain. Combine columns (f) and (g) of line 82. Enter the net gain here and on line 75 above (if a loss, enter -0-)

Form 1040NR (1995)



Other Information (If an item does not apply to you, enter “N/A.”)
A What country issued your passport? B Were you ever a U.S. citizen? Yes No L Have you excluded any gross income other than foreign source income not effectively connected with a U.S. trade or business?



C Give the purpose of your visit to the United States

If “Yes,” show the amount, nature, and source of the excluded income. Also, give the reason it was excluded. (Do not include amounts shown in item M.)

D Type of entry visa and visa number and type of current visa E F Date you first entered the United States Did you give up your permanent residence as an immigrant in the United States this year?

M If you are claiming the benefits of a U.S. income tax treaty with a foreign country, give the following information. See page 17 for additional information. ● Country ● Type and amount of effectively connected income exempt from tax. Also, identify the applicable tax treaty article. Do not enter exempt income on lines 8–15, 16b, and 17b–21 of Form 1040NR. For 1995 (also, include this exempt income on line 22 of Form 1040NR)



G Dates you entered and left the United States during the year. Residents of Canada or Mexico entering and leaving the United States at frequent intervals, give name of country only.

For 1994 ● Type and amount of income not effectively connected that is exempt from or subject to a reduced rate of tax. Also, identify the applicable tax treaty article: For 1995

H Give number of days (including vacation and nonwork days) you were present in the United States during: 1993 , 1994 , and 1995 I If you are a resident of Canada, Mexico, Japan, or the Republic of Korea, or a U.S. national, did your spouse contribute to the support of any child claimed on Form 1040NR, line 7c? If “Yes,” state amount $


For 1994 Yes No ● Were you subject to tax in that country on any of the income you claim is entitled to the treaty benefits? ● Did you have a permanent establishment or fixed base (as defined by the tax treaty) in the United States at any time during 1995?

If you were a resident of Japan or the Republic of Korea for any part of the tax year, enter in the space below your total foreign source income not effectively connected with a U.S. trade or business. This information is needed so that the exemption for your spouse and dependents residing in the United States (if applicable) may be allowed in accordance with Article 4 of the income tax treaties between the United States and Japan or the United States and the Republic of Korea. Total foreign source income not effectively connected with a U.S. trade or business $ J Did you file a U.S. income tax return for any year before 1995? Yes If “Yes,” give the latest year and form number No





N If you file this return to report community income, give your spouse’s name, address, and social security number.

K To which Internal Revenue office did you pay any amounts claimed on Form 1040NR, lines 54, 55, and 58?

O If you file this return for a trust, does the trust have a U.S. business? If “Yes,” give name and address



Printed on recycled paper